pathophysiology of the thyroid and parathyroid glands mudr. pavel maruna
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PATHOPHYSIOLOGY OF THE THYROID AND PARATHYROID GLANDS MUDr. Pavel Maruna. Thyroid gland. Physiology Derived from embryonic thyroglossal duct 2 lobes connected by an isthmus 20 g weight The only significant source of T4, ( T3 ... peripheral conversion) - PowerPoint PPT PresentationTRANSCRIPT
PATHOPHYSIOLOGY OFTHE THYROID AND
PARATHYROID GLANDS
MUDr. Pavel Maruna
Thyroid gland
Physiology
Derived from embryonic thyroglossal duct2 lobes connected by an isthmus20 g weightThe only significant source of T4, ( T3 ... peripheral
conversion)T3, T4: 3-, 4- iodine-derivates of tyrosine
T3 is more potent metabolic factor than T4
Regulation of secretion:TRH - TSH - T4 axis
Thyroid gland
Physiology
Physiology
Total T4 (75-170 nmol / L, 80 - 90 g/den), total T3
Free T4 (fT4) 11 - 22 pmol / L, free T3
TSH (0,5-6,5 mU / L)
USG, Color DopplerScintigraphy (131I, 132I, 99mTc) - differ. dg. of hot / cold nodi,
ectopic goiter, metastases
FNAB (Fine Needle Aspiration Biopsy)
Examination methods
Auto-Ab in diagnostics
(high specificity)
auto-Ab anti-TSH-R binding to different epitops: growth, goiter stimulation ... Graves-Basedow dis. inhibition ... hypothyroid idiopatic
myxoedemaauto-Ab anti-microsomal = anti-TPO (thyroid peroxidase)
... Hashimoto dis.auto-Ab anti-Tg (thyroglobulin) ... x pathogeneticauto-Ab anti-T3... in 40% autoimmmune thyroiditis
Examination methods
USG: Normal thyroid gland
MRI: Nodular goiter
Color USG: Blood flow
Examination methods
131I scintigraphy:Retrosternal goiter
Examination methods
131I scintigraphy:Thyroid cancer - „cold“ nodule
Examination methods
Biopsy (FNAB)
Examination methods
Micro follicular/solid thyroid nodule
Thyroid gland
Pathology
Primary disorders (thyroid gland)Secondary disorders (pituitary gland)Receptor disorders
Thyroid gland
Physiological effects:
• Essential in fetal development• Heat production• Metabolic activity level (activity of cellular Na/K ATP-ase)• Glucose metabolism (uptake of glucose in GIT)• Cholesterol• Haemopoiesis• Bone formation
Thyroid gland
Pathological manifestation
1. Functionalhypothyroidismhyperthyroidism
2. Localgoitermechanic syndrome (dyspnoe, dysfagia, vessels)
3. Systemic (non-endocrine)metastases
EtiologyEtiology
FunctionFunction
Local signsLocal signs
Chronic lymfocytic thyroiditisGraves Basedow dis....
NormalHypothyroidismHyperthyroidism
GoiterMechanic syndrome (dyspnoe, dysfagia, vessel compression
Thyroid gland
Eufunctional goiter
= Goiter with normal hormonal production, x tumor or inflammation
Usually asymptomatic, event. dysfagia, dyspnoe.
High incidence in last decades x iodine prophylaxis and nutritional status
Etiology• iodine insuf. (endemic goiter)• strumigens in food, drugs (SFA, TBCstatics, Li,
resorcinol)• malnutrition• hereditary factors• juvenile goiter (?)• iodine overload (Wolf-Chaikoff effect) - risk of
lymphocyte thyroitidis
Thyroid tumors
Carcinoma malignant lymphoma, sarcoma, carcino / sarcoma, adenoma
2-4x incidence in female
0,5-1,0 % of all carcinomas, increasing incidence !
Risk factors:• ion. irradiation (papillary ca)• high TSH (papillary ca, follicular ca)x relations to jódu
Histological types:
• Papillary (60-70 %) - differentiated, low risk, but possible change to anaplastic form
• Follicular (15-30 %)- " -• Anaplastic – x differentiated, high malignant• Medullary (from C cells)
Thyroid tumors
Thyroid tumors
Clinical coursesolitary note, slow growth, local pain (invasive growth),dysphagia, dyspnoelymph node metastasesdistant metastases
(lungs, path. fractures..)
131I scintigraphy:metastases of papillary ca
Thyroid tumors
Examination methods
USGGammagraphy – usually „cold node" (x iodine accumulation)FNAB (fine needle aspiration biopsy) - cytologyAlternatively: biopsy with Vim-Silverman needle - histology
LaboratoryEuthyroid status calcitonin, PCT, CEA … medullary ca Tg, anti-Tg … non-medullary ca, using for post-surgical
monitoring
Thyroid tumors
Prognosis:Relatively good, better in younger patients, differ. forms
Thyroid tumors
Chronic lymphocytis thyreoiditis
Classification (Volfé)
• Hashimoto dis. (= with goiter)• autoimmune thyr. in children and adults• chronic fibrotic variant• atrophic variant• primary myxedema• Riedl goiter = rare inflamm. form
Autoimmune dis. (primary defect of TS lymphocytes ?)auto-Ab anti-Tgauto-Ab anti-microsomal… and also other auto-Ab
Etiology:
Genetic dispositionsFamily history is positive in 50% !HLA-DR5 variant with goiterHLA-B8, DR3 atrophic variant (see DM type I)HLA-DR2 lower risk30% Turner sy … LTfrequent combination with other autoimmune dis.:
LT in 65% patients with DM type IPOEMS sy
= polyneuropathy, organomegaly, endocrinopathy,
M protein, skin changes
polyglandular sy I, II, III (thyrogastric sy)
Chronic lymphocytis thyreoiditis
Pathogenesis:
Stimuli - may provoke manifestation of latent LT
iodine (cave amiodarone) Liafter delivery - LT in 10% females (usually transient, but 25%
hypothyroidism)cytokine treatment (IFNα, IL-2, GM-CSF) 10% T4
(TPO inhibition, role of NK Ly dysfunction (T4)
Chronic lymphocytis thyreoiditis
Prevalence
In non-selected necropsies: 40-45% fem. and 20% malesFemales 7:1 males, mean age of manifestation 59 yr.
Precancerosis? In thyr. lymphoma – prevalence of LT is 80x higher
Chronic lymphocytis thyreoiditis
Graves-Basedow dis.
Autoimmmune inflammationMost often cause of thyrotoxicosis
Auto-Ab (IgG) anti-TSH R(TRAK, TSI, LATS, LATS protectors)
TH LyThe role of provocative stress factors
(emotion, fever)
Graves-Basedow dis.
Clinical trias:goiter + exophthalmus + tachycardia(oligo- and monosymptomatic formsin old patients)
Hypothyroidism
Etiology
• Primary T4, T3, TSH• Secondary T4, T3, TSH• Congenital receptor deficiency - peripheral resistance to
the T4 action T4, T3, TSH
1. Immunopathology (lymphocytic thyroiditis - Hashimoto´s disease)
2. Iodine deficiency3. Subacute thyroiditis
Hypothyroidism
Manifestation:
• goiter (hyperplasia of thyroid gland - TSH growth stimulation)
• myxedema (forearm, ...)• bradypsychia, lethargy, inability to concentrate• anemia (impaired B12 vit. metabolism)• cardiovascular signs (bradycardia, ventricular dilation)• impaired renal function• neuromuscular system dysfunctions (paresthesia,
muscle weakness)
Congenital hypothyroidism
Hypothyroidism
= cretinism (infants) - mental dysfunction, cyanosis, poor feeding, retardation of bone maturation
Hypothyroidism
Laboratory findings
T4, free T4, T3 TSH cholesterolmacrocytic anemia
Hyperthyroidism
Etiology
primary T4, T3, TSHsecondary T4, T3, TSH (very rare !)
Graves disease (diffuse toxic goiter)autoimmune disorder, autoantibody against TSH-receptorsToxic adenoma (carcinoma) of thyroid glandHashimoto´s thyroiditis (early stage)
Hyperthyroidism
Manifestation
palpitation, hyperkinesia, excesive sweatingthyroid enlargement (goiter)ophthalmopathyupper lid retractionperiorbital edemaprotrusioncorneal involvementsight lossloss of muscle massdiarhheaaccelerated bone maturationdyspnoe
Hyperthyroidism
Laboratory findings
T4, free T4, T3 TSH cholesterol
Ca++
PTH
Glycoprotein, 115 AA precursor, intracel. storageProteolytic removal of N-termin. structure84 AA active hormone
Regulation of synthesis / secretion by ↓ plasma Ca2+
Negative feedback regulation
PTH receptors on plasma membraneAdenylat cyclase, cAMP action
Ca++
PTH
Effects:PTH / Ca2+ regulation Kidney: retention of Ca++ … tubular reabsorption of Ca and
MgBone: release of Ca++ from bone (osteoclastic x
osteoblastic differentiation and actionGIT (via vit. D) absorption of Ca++ from the gut
Ca++
PTH
Effects:
Ca++
Calcitonin (CT)
Product of parafollicular C cells of thyroid glandPeptide, 32 AA, Mv 3,7 kDPrecursor - procalcitonin (inflammatory marker)
Regulation: Stimulation by ↑ Ca2+
Effects:Ca2+ regulation (low importance in humans) Excess or deficiency has not dramatic clinical manifestationKidney: release of Ca2+
Bone: uptake of Ca2+
Ca++
Vitamin D
Vitamin D3 ... CholecalciferolVitamin D2 ... Ergocalciferol
Sterol hormones90 %synthesis in skin10 % food intake
Hydroxylation25-OH- D3 (liver)1,25-OH- D3 (kidney)
Ca++
Vitamin D
Effects:Increase of plasma Ca2+ and PO4 … conditions for bone
mineralizationGIT: facilitation of Ca2+ and PO4 absorptionBone: direct effect of ossification of osteoid tissueSkin: trophic effect (x alopecia)Other tissues: immunological effects
Ca++
Parathyroid glands
4 bodies near both upper and lower thyroid lobe0,05-0,30 g10 - 20 % atypical localization (mediastinum)
Hypoparathyroidism
Etiology:
• Postoperative (after TTE … transitory or irreversible)• Idiopathic … Autoimmune destruction of glands,
combination with Addison dis. + Hashimoto dis.• Congenital - inactive PTH production• Functional (↓↓Mg2+) … transitory
PseudohypoparathyroidismPTH receptor disease in kidneys / or postreceptor dis.... Negative feedback … ↑PTHmanifestation: short staue, obesitas, ↓IQ, brachydactyliaPseudo-pseudo-hypoparathyroidism? incomplete manifestation of pseudohypo-PTH
Hypoparathyroidism
Acute manifestation:
↓Ca2+ + ↑PO4 → neuromuscular hyperactivity
Manifestation depends on actual Ca2+ levelsParesthesia (tingling around mouth,
fingers)Hyperventilation (as alarm reaction) →
↓CO2 → alkalosis → Ca2+ binding to proteins
Tetany (attact begins with paresthesias … painful spasms of extremities and face … flexion of the wrist and MP joints, extension of IP joints
Adrenergic reaction (tachycardia, sweating)
Hypoparathyroidism
Chronic manifestation:“Latent tetany”
HeadacheEpileptic paroxysmsPosterior lenticular cataractECC changes (QT prolongation)Hypotension, cardiac failureDental manifestation (during childhood)Chvostek´s sign (tapping the facial nerve below the
zygomatic arch → twitching of the corner of the mouth and other facial muscles)
Trousseau´s sign (manometer cuff is inflated above systolic pressure for 2 min. → typical carpal spasm)
Hypoparathyroidism
Laboratory signs:
Plasma - Ca2+, urine Ca2+
Plasma - high PO4
Plasma - iPTH
Hypoparathyroidism
Differential diagnostics of tetany
Ca2+ (PTH, bowel resorption, renal loss)- alkalosis (e.g. hyperventilation) K+
Mg2+
- neurogenic (psychogenic) = constitutional spasmophilia
Hyperparathyroidism
Etiology
Primary - Adenoma (3/4, 5-10% atypical localization)HyperplasiaCarcinoma
Secondary - response to Ca2+ (renal failure, vitamin D, pseudohypo-PTH)
Tertiary - chronic stimulation - hyperplasia of parathyr. gland
Hyperparathyroidism
Manifestation
Most patients have no signs!
Laboratory findingsplasma Ca2+, urine Ca2+
plasma low PO4
tubular resorption 80%, clearence of PO4
iPTH urine cAMP ALP
Clinical syndroms
• Bone syndrome(depends on a primary diagnosis)
• Renal syndrome(polyuria, polydipsia, lithiasis, nefrocalcinosis)
• GIT syndrome(constipation, nausea, vomiting)
• Neuromuscular syndrome(muscular weakness, ECG - bradycardia, arrythmia)
• Neuropsychical syndrome(psychosis, somnolence, coma)
Hyperparathyroidism
Hyperparathyroidism
Manifestation
Bone syndromeosteoporosis (RTG, densitometry)diffuse bone painpathological fractureosteitis fibrosa cystica - epulis gigantocellularisLabor. markers: ALP, citrate, urine OH-proline
RTG of wrist
„Salt and peper“
scull
Increased parathyroid activity leading to characteristic
subperiosteal resorption
Hyperparathyroidism
The bone changes are partially reversibleThe same finger pre- and post-treatment for hyper-PTH. Images were taken 6 months apart.
Hyperparathyroidism
Hyperparathyroidism
Manifestation
Renal syndromeCa urolithiasisNephrocalcinosis (soft tissue calcification)Polyuria (water and osmotic diuresis)
GIT syndromeFunctional dyspeptic syndrome
(nausea, vomiting, constipation !)Peptic ulcer (gastrin)Chronic pancreatitis
Hyperparathyroidism
Manifestation
Cardiovascular changesBradycardiaArrhythmia, short QT intervalArterial hypertension
Neurological / neuropsychical syndromeApathyDepressionMyopathy
Hyperparathyroidism
Diagnostics:
Laboratory findings
USGScintigraphyMRI
99mTc-MIBI scintigraphy:Atypical PTH adenoma
PO4 1,25-0H-vit. D3
Ca
PTH
binding of serum Ca
decreased production by the proximal convoluted tubule
retention
renal loss gut uptake of
Ca
secondary hyperparatyreodidism
bone resorption, commonly from subperiosteal regions and tufts of the phalanges, proximal humerus, tibia and femur, and calvarium
Ca++
Differential diagnostics:• Primary hyperparathyreosis ( PTH, Ca2+, HPO4
2-)• Vit. D3 intoxication ( PTH, Ca2+, HPO4
2-)• Adrenal cortex insufficiency
(cortisol blocks bowel resorption of Ca2+)• Malignity (breast cancer, bronchogenic ca, myeloma)
(PTHrP, IL-6 or other cytokine production)• Immobilization• Sarcoidosis (production of 1,25-OH-D3 from macrophages)• Hyperthyroidism
Ca++
Ca++
Differential diagnostics:
• Hypoparathyreosis ( PTH, Ca2+, HPO42-)
• Vitamin D3 deficiency ( PTH, Ca2+, HPO42-)
• Pancreatitis
• Chronic kidney failure ( PTH, Ca2+)• Malnutrition ( PTH, Ca2+, Mg2+)
Ca++